The RWJF Health Policy Research Scholars: Interdisciplinary leaders advancing health equity

1. INTRODUCTION: THE RWJF HEALTH POLICY RESEARCH SCHOLARS PROGRAM

The Robert Wood Johnson Foundation (RWJF) is working alongside other organizations to build a national Culture of Health that provides everyone in America a fair and just opportunity for health and well‐being. ¹ The foundation supports several national leadership development programs to help train a generation of leaders who will use innovative approaches to advance a Culture of Health.

Health Policy Research Scholars (HPRS) is one of these leadership programs. ² HPRS is a 4‐year program for doctoral students who are from historically marginalized backgrounds or are underrepresented in their discipline and who want to: improve health, well‐being, and equity; challenge long‐standing, entrenched systems; exhibit new ways of working; collaborate across disciplines and sectors; and bolster their leadership skills. By providing training in health policy, strategic thinking, and crafting actionable research questions that can inform solutions to advance health equity—as well as mentorship and coaching—HPRS is developing a new cadre of research leaders who will build a Culture of Health in their disciplines and communities. Scholars bring their own perspectives, passions, and lived experiences to their work and the program, extending the ways in which a Culture of Health can be achieved.

We are delighted to have an accompanying Commentary by Dr. Thomas LaVeist, ³ the founding director of HPRS, providing a firsthand account of the vision and birth of the program, as part of this special issue.

2. SPECIAL ISSUE OVERVIEW: HEALTH EQUITY

This special issue highlights impactful and innovative work from the HPRS community and demonstrates the myriad ways in which research can inform systems and policy change to advance a Culture of Health. Each paper is led by a current or former HPRS scholar in collaboration with other HPRS scholars, co‐investigators, and mentors. This issue represents a range of disciplines and topics that are salient to advancing a Culture of Health. A critical aspect of a Culture of Health is health equity; these manuscripts address barriers and opportunities for enabling everyone to live the healthiest life possible.

Structural inequity in our society leads to poor health, and the distribution of inequity is driven by the marginalization of social identities based on race, ethnicity, gender, immigration status, nationality, sexual orientation, and many other characteristics. In the United States, race has had the strongest and most persistent signal related to inequity, and provides a historical context and framework for understanding structural inequities in general. Dr. Camara Jones describes racism as a system of structuring opportunity and assigning value based on the social interpretation of how one looks (i.e., “race”), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources. ⁴ Dr. Jones describes three kinds of racism: institutional, personally mediated, and internalized. ⁵ Institutional racism, or structural racism, is defined as the differential access to goods, services, opportunities, or risk based on race. Personally mediated racism, or interpersonal racism, consists of both prejudice (differential assumptions about the abilities, motives, and intentions of others according to their race) and discrimination (differential actions toward others according to their race). Internalized racism is the acceptance by members of stigmatized races of the negative messages about their abilities and intrinsic worth.

In this Health Equity theme issue, we have a collection of articles that tackle various aspects of health equity, including structural inequities, interpersonal racism, the importance of intersectionality, and data equity.

3. STRUCTURAL INEQUITIES

The laws and policies that enacted residential racial segregation and the subsequent community disinvestment have had one of the most persistent effects on the health of racially minoritized populations. Current measures of community vulnerability, such as the area deprivation index (ADI) and the social vulnerability index (SVI), are tightly associated with historical residential segregation, and these measures of community vulnerability have been associated with inequities in healthcare delivery (e.g., availability of mental health services) ⁶ and health outcomes (e.g., COVID‐19 incidence and mortality). ⁷ In this issue, McGee‐Avila et al. examined the location of cancer treatment among adults diagnosed with breast, colorectal, or invasive cervical cancer and found significant differences in geospatial patterns of cancer treatment by race/ethnicity, insurance type, and area‐level factors, even after controlling for sociodemographic factors and tumor characteristics. ⁸ For example, Black patients and patients living in census tracts with the highest quintile of social vulnerability (as measured by SVI) were more likely to receive treatment within their residential county. The authors concluded that structural barriers may limit opportunities for disadvantaged groups to access specialized care outside of their immediate residential county, which may in turn contribute to inequities in cancer care and outcomes.

Residential segregation also contributes to differential educational opportunities and outcomes, which are well‐established determinants of inequities in health. The link between education and health, however, is reciprocal, and health inequities can also maintain educational gaps. For example, low birth weight has been associated with decreased cognitive performance. ⁹ And control of chronic diseases like asthma has led to fewer school absences and improved academic performance. ¹⁰ Few studies, however, have examined the contribution of inequitable healthcare to educational outcomes. In this issue, Drescher and Domingue created a measure of childhood physician supply (including pediatricians and family physicians) at the school‐district level and explored how it varied across the United States and whether it was related to academic performance. ¹¹ They found that children in rural areas, especially rural children of color, had much lower supplies of child physicians. Controlling for other non‐educational factors associated with academic performance, the researchers found that for every additional child physician, there was an increase in academic performance by approximately 4% of a grade level. The magnitude of impact was more profound for pediatricians; for every additional pediatrician, there was a roughly 8% increase in grade level performance. Districts in the lowest tertile of physician supply were particularly impacted by the addition of one child physician, which increased academic performance by the equivalent of 90 days of school learning, or half of a grade level of achievement. These findings highlight the reciprocity of education and health and the importance of not only addressing educational gaps as a path to more equitable health but also addressing health gaps as a path to greater equity in education.

Immigrants to the United States face numerous structural barriers to health, including exclusion of non‐citizens from government programs for health insurance and those that address health‐related social needs such as food insecurity (e.g., Supplemental Nutrition Assistance Program). In this issue, Guadamuz and Qato examined an understudied pathway by which these structural barriers can lead to inequitable health: cost‐related nonadherence to medications. ¹² Analyzing data from the National Health Interview Survey, they found that non‐citizens were more likely than citizens to report not being able to take prescribed medications due to cost. This disparity was explained by differences in health insurance and food security, indicating that policies limiting access to basic services for immigrants also limit their ability to attend to their own health. Non‐citizens were also less likely to ask for cheaper medications in comparison to citizens, likely reflecting the disempowerment that socially marginalized patients feel when navigating health systems. These findings elucidate an important mechanism by which inequitable social policies lead to inequitable health.

Occupational inequities can also adversely affect health outcomes. Racial and ethnic minorities are more likely than the majority White population to be frontline workers and may experience more job‐related stress due to the added burdens associated with structural racism. Haro‐Ramos et al. sought to determine whether Black and Latino frontline workers, in comparison to White frontline workers, experienced higher pandemic‐related stress, a key driver of poor mental health (e.g., anxiety and depression) and other health outcomes. The study used a California database of registered voters in 2020 and examined responses to the Pandemic Stressor Scale, which assesses stress from experienced (or anticipated) problems related to limited income (e.g., to cover basic necessities), job instability, lack of paid sick leave, lack of childcare, and/or reduced wages or hours in the context of the COVID‐19 pandemic. The researchers found that, even after adjustment for individual socioeconomic status and neighborhood‐level SVI, Black frontline workers had higher pandemic‐related stress than White frontline workers. ¹³ Latino workers had higher stress regardless of their frontline worker status. These findings point to the importance of structural policies that address the needs of workers (e.g., paid sick leave and childcare), particularly those on the front lines at high risk of adverse economic and health outcomes.

Within low‐income, racially minoritized communities, rates of high school graduation are significantly lower than those of more affluent, White communities. This observation has often been attributed to hopelessness and self‐devaluation among low‐income minority students, which can be signs of internalized racism. In this issue, however, Larez et al. argue that student disengagement should be viewed through a lens of resistance and critical race theory, understanding that limited educational opportunities for socially marginalized populations have been a central part of structural racism. ¹⁴ Despite the 1954 Brown versus Board of Education Supreme Court decision that made segregated educational systems illegal in the United States, the majority of schools remain racially and economically segregated, with low‐income communities having less funding and fewer resources (e.g., teachers, special programs) for their neighborhood schools. Understanding this background of structural racism is critical to better contextualizing the circumstances of minoritized students and, in turn, better understanding how to re‐engage them and address their needs. Illustrating the importance of this broader context, Larez et al. engaged students at a continuation high school in central California using a Youth Participatory Action Research (YPAR) framework, providing participants with the training needed to carry out a research project exploring reasons for low attendance at the school. ¹⁴ The students found that 72% of survey respondents were caregivers for family members at home and that the prevalence of depression symptoms was much higher than typically seen in this age group. These findings point to structural sources of school disengagement and argue against the common assumption that this phenomenon arises from a “culture” of poverty or internalized racism. The YPAR process provided student insight into the reforms necessary to support this population and work toward educational equity.

4. INTERPERSONAL RACISM

The chronic stress of interpersonal racism (e.g., discrimination) activates a series of maladaptive disruptions to neuroendocrine systems (e.g., hypothalamic–pituitary–adrenal axis), cardiovascular systems (e.g., heart rate variability), and immune systems that cause systemic inflammation and lead to poor physical and mental health. For example, discrimination has been associated with cortisol dysregulation, high C‐reactive protein levels, coronary artery calcification, carotid intima media thickness, and cellular inflammation. ¹⁵ Chronic exposure to discrimination (e.g., in the workplace, while shopping, or in school) has been associated with a range of chronic diseases, including hypertension, asthma, breast cancer, and all‐cause mortality.

Police discrimination and violence have been a historical and contemporary source of trauma and control for Black and other racially minoritized populations in the United States. ¹⁶ In this issue, Asabor et al. analyzed national data on murders perpetrated in the United States between 2013 and 2021 by off‐duty police officers and the coverage of those killings by national and local news media. ¹⁷ They found that Black men were the most frequent victims of off‐duty police killings. When comparing off‐duty to on‐duty police killings, however, Black women were the group most disproportionately victimized by off‐duty officers. News media analysis showed that if the victim was Black or Latino, there were three times higher odds that the media would report the victim's race and that the killing was perpetrated by an off‐duty officer. Qualitative analysis elucidated the contexts in which the killings by off‐duty officers occurred, showing that they often reflected violent interventions within officers' own social networks and that off‐duty officers often intervened when intoxicated and tended to escalate rather than de‐escalate situations. These findings shed light on an aspect of racialized police violence that has previously received little attention.

Also in this issue, Anderson et al. conducted a survey of Black and Latino adults in 2021 to explore whether breaches of trust through state‐sanctioned discrimination and structural violence were associated with lower levels of trust in COVID‐19 vaccine‐related actors (pharmaceutical companies, various government entities, usual sources of care, vaccine clinics, and the Food and Drug Administration). ¹⁸ The researchers asked about knowledge of the circumstances of the George Floyd murder, the Tuskegee Syphilis Study, and the U.S. Immigration and Customs Enforcement (ICE) detainment centers, as well as respondents' satisfaction with the government's handling of the George Floyd investigation. Among Black respondents, lower satisfaction with the George Floyd death investigation was associated with lower levels of trust in pharmaceutical companies, state‐elected officials, and the Trump‐Pence administration; it was not associated with erosion of trust in direct sources of healthcare delivery, information, or regulation (or the Biden‐Harris administration). Among Hispanic respondents, greater knowledge of ICE detainments was associated with lower trustworthiness ratings of elected state officials. This study adds to the growing body of work demonstrating that state‐sanctioned discrimination and structural violence in minoritized communities are associated with correspondingly lower levels of trust in institutions promoting COVID‐19 vaccine uptake, pointing to the vital role of trust in addressing health inequities.

Residential segregation results in less exposure to people from different racial groups, which can lead to downstream challenges in interracial interactions. Interracial anxiety is defined as feelings of discomfort, uneasiness, and worry during interracial encounters and has been associated with lower quality patient interactions. Plaisime et al. analyzed data from a retrospective longitudinal study of physicians in training surveyed over the course of medical school and residency, and explored potential associations between non‐Black students' interracial contact prior to medical school—the racial compositions of their childhood neighborhoods, college campuses, and friend groups—and their interracial anxiety with Black patients. ¹⁹ The authors found that medical students and residents from less diverse neighborhoods and with less diverse friend groups had more interracial anxiety. These findings highlight another pathway by which racial segregation can lead to inequities in health and health care and the importance of considering racial socialization in selecting and training a healthcare workforce equipped with the skills to address those inequities.

5. INTERSECTIONALITY AND DATA EQUITY

While the majority of papers in this issue have focused on race and ethnicity, we again acknowledge that there are many ways that structural inequities can intersect to affect individuals and populations based on other aspects of social identity, including gender, immigration status, nationality, sexual orientation, and place of residence. In the United States, rural Americans generally have less infrastructure and healthcare resources than Americans living in suburban and urban areas. Income inequality, social cohesion, and neighborhood walkability are all factors that have been associated with physical activity, which is promoted as an essential component in combating the obesity epidemic in both urban and rural areas. Baxter et al. conducted a study to examine whether these factors were salient in the rural setting, using a telephone survey in Southeastern US rural counties in 2020–2021. ²⁰ They found that people in communities characterized by high social cohesion were 2.5 times as likely to be active than those with low social cohesion, while neighborhood walkability was not associated with physical activity. This points both to the importance of community as a driver of improvements in health and health equity and to the necessity of representative data to draw conclusions applicable to rural and other undercounted communities.

Health equity research is only as strong as the data that we use to draw our conclusions. It is important in generating and analyzing data that we pay attention to the ways in which multiple axes of oppression can compound the effects of structural inequities on health. In order to incorporate this intersectionality of identities into efforts to promote health equity, we must be able to accurately measure health across different populations. Many of the methods we use to measure health status, however, have not been evaluated to ensure that they adequately assess the health and experiences of populations at the intersection of multiple identities. Cintron et al. evaluated the measurement equivalence (i.e., invariance) of the most commonly used measure of depression, the Patient Health Questionnaire (PHQ). ²¹ They evaluated the equivalence of the PHQ across 16 subgroups at the intersection of age, gender, race (Black/non‐Black), and education. They found the PHQ to have relatively consistent measurement characteristics across groups, indicating that it can be used reliably to evaluate inequities in depression care and outcomes across intersectional groups. Similar research is needed to ensure that other commonly used clinical and research instruments are valid across different populations.

Further illustrating the importance of data equity, the Commentary by Lee et al. notes that the current ways of collecting, analyzing, interpreting, and reporting health data (the “data life cycle”) often obscure meaningful data. ²² For example, some racial and ethnic groups are not measured at all, and their lived experiences are not included in the data. Data are rarely disaggregated to allow for granular analysis within racial and ethnic subgroups (even when such data are available). And the failure to report how race and ethnicity are conceptualized and operationalized leads to missed opportunities to advance the science of racial/ethnic health equity. Lee et al. offer several recommendations to address these and other shortcomings in data equity while taking care to highlight instances where data disaggregation could in fact harm communities if misimplemented. ²²

6. CONCLUSIONS

These articles illustrate the breadth of issues that the Health Policy Research Scholars investigate, which go far beyond the walls of healthcare to some of the root causes of inequity. These must be addressed if we are to build a Culture of Health and achieve true health equity. We are delighted to share the work of these health policy scholars with you all.

FUNDING INFORMATION

No funding to report.

Peek ME, Goheer A, Saha S. The RWJF Health Policy Research Scholars: Interdisciplinary leaders advancing health equity. Health Serv Res. 2023;58(Suppl. 2):145‐149. doi: 10.1111/1475-6773.14186